There are different types of A&E departments
There are three main types of A&E departments in England.
Type 1 departments are what most people might traditionally think of as an A&E service. They are major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients, for example patients in cardiac arrest. Type 1 departments account for the majority of attendances (63 per cent in 2018/19).
Type 2 departments are consultant-led facilities but for single specialties, for example, dedicated to treating only eye conditions or only dental problems.
Type 3 departments treat minor injuries and illnesses, such as stomach aches, cuts and bruises, some fractures and lacerations, and infections or rashes. Type 3 departments, which can be routinely accessed without an appointment, include minor injury units and walk-in centres.
Major (type 1) and specialist (type 2) departments are operated by NHS trusts. Type 3 departments are operated by the NHS and by the independent sector.
As of March 2020, there were 132 NHS trusts operating type 1 A&E departments. Each trust may operate more than one type 1 A&E department, and, based on audit data from the Royal College of Emergency Medicine, there are approximately 180 individual type 1 emergency departments in England.
There is considerable variation in the activity at different departments. In quarter 3 (October to December) 2019/20, the NHS trust with the most A&E attendances saw more than 95,000 people across its different A&E departments. This was ten times the number of attendances seen in the NHS trust with the least activity over this period (see Figure 1).
Measuring the performance of A&E departments
The most high-profile measure of A&E performance in England is the four-hour standard. This refers to the pledge in the NHS Constitution that at least 95 per cent of patients attending A&E should be admitted to hospital, transferred to another provider, or discharged within four hours.
Figure 2 shows the emphasis placed on the four-hour standard as 8 per cent of patients are admitted, transferred or admitted in the 10 minutes before they would cause a breach of the standard.
A&E waiting times are often used as a barometer for overall performance of the NHS and social care system. This is because A&E waiting times can be affected by changing activity and pressures in other services such as the ambulance service, primary care, community-based care and social care services. For example, patients cannot be admitted quickly from A&E to a hospital ward if hospitals are full due to delays in transferring patients to other NHS services or in arranging social care.
Being treated quickly in A&E is clearly important for both the experience and clinical outcomes of patients. However, measuring the proportion of people seen within four hours does not provide a full picture of how A&Es are performing. For example, two different A&Es could see the same proportion of patients within four hours but have very different average waiting times. We should be cautious about placing too much emphasis on the four-hour standard or any single measure of A&E performance. The safety and quality of care, as well as patient experience, are as important as how rapidly care is provided.
In addition to waiting times, the quality of A&E care can also be measured through clinical indicators such as the proportion of patients who re-attend A&E within seven days of their first attendance (9 per cent of A&E attendances in 2018/19 were re-attendances within seven days of the original attendance). Other measures, such as the time a patient waits to see a clinician in A&E, are also now recorded.
The Care Quality Commission (CQC) also rates the safety and effectiveness of A&E services. Urgent and emergency services receive the lowest CQC ratings of core hospital services with more than half being rated as ‘inadequate’ or ‘requires improvement’ (see Figure 3).
In the 2018 British Social Attitudes Survey, A&E services also received lower satisfaction scores from the general public than other services including outpatients and admitted inpatient care. However, the 2018 national survey of patients who have used urgent and emergency care services shows these services receive high satisfaction scores overall (see Figure 4), although more can be done to improve communication with patients over how long they can be expected to wait and what symptoms they should watch for after they are discharged.
In 2018, NHS England began a review into NHS access standards including the four-hour A&E standard. This review focuses on whether existing standards – some of which were developed nearly 20 years ago – should be updated or supplemented. Several new standards for A&E services were proposed by NHS England in March 2019, including measures of how long patients wait before assessment or treatment in A&E. These new standards have been tested in 14 pilot sites across England. It was expected that recommendations on changes to the four-hour standard would be proposed in spring 2020, but these proposals have been delayed to later in the year due to the impact of coronavirus (Covid-19).
What has happened to A&E waiting times in recent years?
A&E waiting times have worsened substantially over the past decade, as the NHS has experienced a sustained period of financial austerity and staffing pressures. The NHS has not met the four-hour standard at national level in any year since 2013/14, and the standard has been missed in every month since July 2015 (see Figure 5).
In 2018/19, 88.0 per cent of patients spent four hours or less in A&E, far below the 95 per cent standard. The four-hour standard is measured across all A&E departments, but performance is poorest in type 1 A&Es and this is where the majority of breaches of the four-hour standard occur. For example, in February 2020, 98.6 per cent of patients were seen within 4 hours in type 3 A&E departments but only 73.0 per cent of patients were seen within four hours in type 1 A&E departments.
It is important to note that the vast majority of patients are still seen within four hours of arrival at A&E. The English NHS also compares favourably with other countries on providing rapid access to emergency care. However, A&E performance has fallen compared to recent years and pressures on services continue to increase.
Why are patients waiting longer in A&E departments?
Patients are waiting longer in A&E departments due to a wide range of factors including rising demand for services and reduced capacity to meet this demand.
Rising A&E attendances
The number of people going to A&E has risen substantially over time. In 2018/19 there were 24.8 million attendances at A&E departments – the equivalent of 68,000 attendances each day on average.
Between 2011/12 and 2018/19, A&E attendances grew on average by 2.1 per cent each year and increased by 3.3 million (16 per cent) in total. This is the equivalent of an extra 9,200 A&E attendances each day. The growth in attendances has been higher in type-3 A&Es, compared to type 1 or type 2 A&Es.
Rising emergency admissions
However, the increased pressure on A&E departments is more closely associated with rising numbers of emergency admissions to hospital rather than the increase in A&E attendances. In recent years, as demand for hospital inpatient care increased, the capacity to meet this demand has come under increasing pressure as the number of hospital beds reduced and the NHS experienced severe staff shortages (see our explainers on A&E waiting times, hospital beds and delayed discharges for more information).
Fewer hospital beds
Patients admitted to hospital require a bed to be available. Although medical advances have reduced the average length of time people spend in hospital and allow beds to be ‘turned around’ or made available again more quickly, rising emergency admissions are placing increasing pressure on a hospital bed stock that has been reduced over the years. Our more detailed recent analysis shows that the number of hospital beds for overnight stays continues to decrease even as admissions continue to rise.
These pressures are demonstrated by high levels of bed occupancy in NHS hospitals, which are closely associated with longer waiting times in A&E. Particularly in the winter months, hospitals are routinely operating with bed-occupancy rates above 92 per cent – the level at which the Department of Health and Social Care suggests that hospitals will struggle to deal with emergency admissions.
One of the clearest indications of the link between A&E waiting times and hospital bed occupancy is the number of patients who experience ‘trolley waits’ in A&E departments – ie, a long wait between a decision to admit the patient being made in A&E and the patient actually being admitted to a hospital bed. The number of ‘trolley waits’ can be affected by variation in how different hospitals arrive at (and record the time of) the ‘decision to admit’. Because of this, NHS Digital has begun to produce data on the number of patients who spend a total of 12 hours or more in A&E. Over the past few years, this number has rapidly increased (see Figure 6). While these extremely long waits represent a very small proportion of the 24.8 million patients seen in A&E last year, trolley waits can cause significant distress for patients and are a clear sign of the pressure A&E departments are under.
Pressures on other services and changing clinical practice
It has been suggested that one of the causes of increased pressure on A&E departments over the past decade is people attending unnecessarily because, for example, they can’t get an appointment with their GP or are confused about where to go for treatment. In particular, it has been argued that contractual changes in 2004, which removed responsibility for out-of-hours care from GPs, led to an increase in attendances. There is limited evidence to support this theory, with little change in the proportion of attendances at type 1 A&E departments outside working hours (Nuffield Trust 2015).
Delays in discharging patients who are medically fit to leave hospital (known as ‘delayed transfers of care’) are another factor driving up bed-occupancy rates, preventing beds being available for new patients requiring admission from A&E. In January 2020 there were more than 105,000 delayed days in acute hospital care. The majority of delayed transfers (60 per cent in January 2020) can be attributed to delays within the NHS (when there is a delay in patients being transferred to receive care from a different NHS provider such as a community hospital). However, the proportion attributable to social care (ie, patients waiting for care to be arranged at a residential or nursing home or for a care package at home to be developed) has increased over recent years. This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years while demand for social care services has been increasing.
Around 9 per cent of people who attend A&E are discharged without requiring treatment, and a further 32 per cent receive guidance or advice only (NHS Digital 2019). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted to a hospital bed may well have attended appropriately because they required assessment or clinical advice from A&E professionals.
Recent analysis has also indicated that waiting times in A&E may be increasing due to advances in medical practice. For example, some patients who would previously have been admitted to hospital can now be fully treated in A&E with more investigations and treatments. Patients with simpler clinical needs who could be treated quickly in A&E may now also be increasingly treated out of hospital, for example, being treated by ambulance services at the scene of an injury. While these advances are delivering better care, they mean that patients attending A&E may spend longer in A&E departments receiving more complex and time-consuming treatment than in the past.
A&E departments face longstanding challenges in recruiting and retaining sufficient staff to cope with rising demand. The Royal College of Emergency Medicine notes that emergency medicine has a high attrition rate from doctors in training, high early retirement rates for experienced clinicians, and significant reliance on temporary locum clinical staff. In the most recent General Medical Council survey, nearly three-quarters of emergency medicine trainees rated the intensity of their workload as heavy or very heavy, substantially more than any other specialty.
A range of national policies has been put in place over recent years to boost the numbers of clinical staff in A&E departments through increased recruitment and improved retention of existing staff. Between 2012 and 2019 the number of emergency medicine consultants increased by 7 per cent each year. This has meant the number of attendances per consultant has fallen from roughly 12,300 a year in 2011 to 8,400 a year in 2018. Over this time, other professional roles, such as advanced clinical practitioners and physician associates, have also been developed to play a greater role in delivering A&E services to relieve pressures on departments.
However, it remains difficult to recruit and retain sufficient staff in emergency care and other key services. Shortages of nurses and medical staff are also reported in mainstream specialties such as acute general medicine. Staffing shortages in these key areas will reduce the ability of hospitals to admit patients quickly from A&E departments or to provide specialist advice to patients within A&E departments who could be treated and discharged, further increasing waiting times.
A picture of activity at A&E departments
Age of patients
NHS Digital publishes detailed annual reports of activity at A&E departments in England. These reports show that the age-profile of patients attending A&E has remained relatively stable over the past decade, but people aged 65 and over account for a larger share of A&E activity per head than adults and children (see Table 1).
|Group||A&E attendances||ONS population||Attendances per 1,000 head|
People living in the most deprived 10 per cent areas in England had a far higher number and rate of attendances at A&E compared to other groups (see Figure 8). A&E attendances were twice as high for people in the most deprived areas as in the least deprived.
The first large-scale research into attitudes and perceptions towards emergency care from the 2018 British Social Attitudes Survey found people living in deprived areas: are more likely to prefer A&E departments over their GP to get tests done quickly; find it more difficult to get an appointment with their GP; and think A&E doctors are more knowledgeable than GPs.
One of the defining characteristics of emergency medicine (and general practice) is its undifferentiated case-mix, ie patients attend an A&E department without prior testing or categorisation of their medical condition and health needs. Figure 9 shows the wide variety of conditions that are treated in A&E departments.
Nearly 60 per cent of A&E attendances end with the patient being discharged, with slightly more than 16 per cent of patients being admitted to hospital and smaller proportions of patients being transferred or referred to other services. More than 40 per cent of patients arriving by ambulance are admitted to hospital from A&E, compared to only 9 per cent of patients who arrive by other means (including self-referral and transport) (see Figure 10).
Winter is the one of the most challenging times for health and care services in general and A&E departments in particular.
Although the volume of A&E attendances is not substantially higher in winter, the demand for hospital admissions and more intensive medical care increases. Demands can rise due to increased prevalence of influenza-like illness, respiratory diseases associated with colder weather such as asthma and pneumonia, and infectious winter vomiting bugs like norovirus.
These pressures also affect NHS staff, further adding to pressures on services as staff sickness increases over winter. The supply of hospital beds can also be heavily affected by norovirus outbreaks, which can lead to entire wards being shut and deep-cleaned. This combination of increased demands and reduced capacity leads to patients waiting longer in A&E departments over the challenging winter months.
Each year NHS organisations and local groupings of organisations in ‘A&E delivery boards’ produce plans of how they will increase capacity and cope with rising demand. These include: using any additional government funding to help the NHS cope over winter (over the past decade, it has become common practice to give the NHS additional funding for winter pressures – and this funding often comes at short notice.); opening temporary ‘escalation beds’ to admit patients when demand surges; and cancelling planned operations to allow staff and hospital beds to be prioritised for patients arriving at hospital in an emergency.
However, as staffing pressures and reductions in the number of hospital beds have become endemic to the NHS over recent years, long waiting times in A&E departments throughout the year are common.
While rising demand for services means that the NHS is treating more people than ever before, patients are waiting longer for the care they need in A&E departments.
A&E departments have constant interactions with other parts of the hospital, for example, to request diagnostic tests and to transfer patients. A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system. High levels of hospital bed occupancy, delays in transferring patients out of hospital, and staff shortages throughout the urgent and emergency care system have all had an impact on A&E waiting times. The four-hour A&E waiting time standard is one of the most high-profile indicators of how the NHS is performing. The declining performance against this waiting time standard is a clear indication of the pressures the wider health and care system is under.
The new five-year funding deal for the NHS provides welcome relief after the longest funding squeeze since the NHS was established. However, it will not provide enough resources for performance to recover against these standards while also developing new and better services. Taken alongside staffing shortages, this means there is little prospect of waiting times in A&E departments being restored to previous levels or the national standard in the near future.
It saddens me that many of Australian AE training posts are filled by UK graduates. It also saddens me that there are nearly 50% AE middle grades who are non-trainee posts. Traditionally these are filled by non-EU doctors from Indian and African countries. With the immigration changes these doctors have stopped coming to UK.
While we bust the myths let us also see what is the solution for acute shortage of AE doctors, why our trainees are happy to go to Australia but don't want to do their training in UK and let us learn lessons.
We owe it to our patients and also for our staff. If not quality will drop, cost will increase and both patients and staff will suffer.
I am very sad and also somewhat resentful that doctors are going to Australia.
I am visiting my daughter in Melbourne very soon having been their for three and a half months in 2011.
I was surprised to discover how much must be spent on admin in the Australian system.As a patient with Medicare I had to either pay the total amount and then claim a large percentage back via a Medicare office or fill in many forms or or if they bulk billed then I had to pay the percentage required at the surgery.
One young Australian said he would not take his children to A@E in Melbourne as there would be too much blood??
WE do not hear of the problems in otherrcountries. I have a relation in Vancouver and she had to wait for three days on a trolley in a corridor as they did not have a bed to admit her.
I intend doing some research whilst I am in Australia to find out just exactly how it works.
I wish you all the very best.PS I was admitted to hospital as an emergency ,spent four days there and received surgery eight weeks later. Excellent all round
Much of what is described in this paper is common sense when looking at the impact of policy decisions, investment, geographical pressures, training and recruitment issues and inescapable demographic changes and pressures.
My experience of working in primary, acute and ambulance services at a senior level and at a more remote strategic level tells me that the vast majority of all staff go to work and do a great job with what they have and that there are a great many who are innovative and creative.
The simple fact is that this as your paper highlights a complex area with an incredible number of variables.
It is important to be realistic and honest about what is not only affordable but what is achievable taking into account all the available resources.
Well done again. Keep up the great work - busting the myths and highlighting the issues.
The 'front door' issues make the headlines, but there are untold triumphs and issues lurking beneath that do not get the political and press coverage.
We have an opportunity as clinicians to work with all stakeholders at trust and strategic level to address these issues, with the patient at the centre of the whole scenario - the QIPP savings will follow!
I too enjoy reading the Kings Fund's measured take, on what can be at times a visceral discussion about the future of the NHS, inevitably tarnished with whatever political hue one would wish - a nessecary evil in a system borne by politicians.
We have taken the number used in the data sheet that accompanies the HSCIC report that says: 39% of patients were discharged with no follow-up required. So they could have consumed lots of activity before they were discharged, but with no further treatment required.
But the Focus on A&E report says that, for first A&E treatment, 34.4% of patients received guidance/advice only. So perhaps the true number of patients receiving no treatment is somewhere between the two.
I do think however that we need to be careful about how we class 'guidance only'. Though it is likely that this advice could be given in other healthcare settings, we shouldn't discount its value to patients who felt they needed to see a healthcare professional at short notice.
We have private and public ED's however it is common for the more electronically advanced ED's to charge overseas visitors $400 for an attendance and the you would be eligible to get some of that back from Medicare and the rest from a private insurer ( if you have taken out that level of travel insurance before you travel). Those ED's not so well resourced would likely charge the Medicare rebate only. However Australain health care is based on user pays- we pay for scripts, always GP visits, unless you go you a bulk billing clinic. This is the way it works.
There is no NHS philosophy here for those who can pay and if you are fortunate enough to be able to afford to visit Oz -you pay.
If you have a life threatening illness all bets are off and any ED will ignore all of the above and care for you- even top private ED's would not chase the dollar - if you needed heart surgery after a heart attack they would get on with it and suck it up. This is not infrequent.
TAC - transport accident commission would cover all costs if you are injured on our roads
WC - work cover would cover all costs if you got injured at work
DvA - would cover all costs if ever you out your life on the line for fellow countryman
It's different to the UK but it's not a bad system.
Do not travel and expect fish and chips- unfair. We would grill the fish and have salad and you would feel healthier afterwards.
Enjoy Melbourne- my family have enjoyed my deflection to Oz 25 years ago and on their visits to Oz have needed to utilise the services occasionally and loved it -
Advice. IF YOU PICK UP A MEDICARE CARD FROM A MEDICARE OFFICE AS SOON AS YOU ARRIVE IN THE COUNTRY- to which you are entitled - IT IS LIKELY YOU WILL BE CHARGED NOTHING IF YOU ARE SICK ENOUGH TO NEED ED. You will need to pay a copayment at the GP as everyone does. Unless you go to a bulk billing clinic.
As to why the registrars are coming- look at the case mix and skill base they get here. The days of Oz coming to practice on the POHM's is over. POHm's come here because the training model for ACEM is different and the lifestyle and attitude is wonderful for anyone.
Don't moan that they come- find out what we offer and take it back to UK
The reverse is true. A number of representatives from UK hospitals and government agencies have been recruiting here for UK roles. The money is better in the UK and the bureaucracy problem is less.
The issues we have are globally universal:
Trauma doctors and experienced nurses are in short supply.
Growth in aged care health is growing very quickly
Trolley block is being addressed to avoid ambos being stuck at emergency departments waiting for a A&E bed.
Whats new? Every country has these problems. Doctors and nurses in Australia are paid roughly the same as in the UK if you analyse the higher living costs in Australia and purchasing power.